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The nurse observes a client with schizophrenia sitting alone, laughing occasionally, and turning his head as if listening to another person. The nurse assesses this behavior to indicate that the client is experiencing auditory hallucinations and says,
- A. Are you hearing something?
- B. It's a beautiful day, isn't it?
- C. Would you like to go to your room to talk?
- D. Would you like to take some of your PRN medication?
Correct Answer: A
Rationale: Asking if the client is hearing something validates the observed behavior and opens dialogue about hallucinations, unlike unrelated or premature interventions.
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Which of the following attitudes would be best for the nurse when the client who has schizophrenia acts as though the nurse is not trustworthy or that his or her integrity is being questioned?
- A. That the client is correct and the nurse is not trustworthy
- B. That the client wants to insult the nurse
- C. That the client's behavior is a part of the illness
- D. That the nurse's actions have failed
Correct Answer: C
Rationale: Recognizing suspicious behavior as part of schizophrenia avoids personalizing it, maintaining therapeutic objectivity, unlike assuming distrust or failure.
The client with schizophrenia makes the following statement. 'I just don't know how to count. The sky turned to fire. I have a ball in my head.' The nurse documents this entire statement as an example of
- A. Flight of ideas
- B. Ideas of reference
- C. Delusional thinking
- D. Associative looseness
Correct Answer: D
Rationale: The fragmented, poorly related thoughts demonstrate associative looseness, not flight of ideas (rapid but connected thoughts), ideas of reference, or solely delusional thinking.
During the nursing assessment, a client describes constantly hearing voices mumbling in the background. The client denies that the voices are telling him to do anything harmful. The nurse documents that the client is experiencing which of the following?
- A. Command hallucinations
- B. Auditory hallucinations
- C. Olfactory hallucinations
- D. Gustatory hallucinations
Correct Answer: B
Rationale: Hearing non-command voices indicates auditory hallucinations, the most common type in schizophrenia, distinct from command, olfactory, or gustatory hallucinations.
The parents of a young adult male who has schizophrenia ask how they can recognize when their son is beginning to relapse. The nurse teaches the family to look for which of the following?
- A. Excessive sleeping
- B. Fatigue
- C. Irritability
- D. Increased inhibition
- E. Negativity
Correct Answer: B,C,E
Rationale: Fatigue, irritability, and negativity are early relapse signs, unlike excessive sleeping or increased inhibition, which are less specific to schizophrenia relapse.
A client with schizophrenia reads the advice column in the newspaper daily. When asked why the client is so interested in the advice column, the client replies, 'This person is my guide and tells me what I must do every day.' The nurse would best describe this type of thinking as which of the following?
- A. Referential delusion
- B. Grandiose delusion
- C. Thought insertion
- D. Personalization
Correct Answer: A
Rationale: Believing the advice column has personal significance indicates a referential delusion, unlike grandiose delusions (exaggerated self-importance), thought insertion, or personalization.